Ineffective Anticoagulation Research Articles

Investigation about the present status of renal replacement therapy in department of intensive care unit in Tianjin

To understand the current state of renal replacement therapy (RRT) in intensive care unit (ICU) of Tianjin public hospital, and to provide scientific evidence and direction for homogenized management and overall level improvement of RRT in Tianjin. The questionnaires were distributed to the chief or key staff of 33 ICUs from 32 public hospitals in Tianjin by clinical quality control center for critical care medicine of Tianjin and ICU of Tianjin Third Central Hospital. The RRT data of ICUs from January 2020 to December 2021 was collected, including the type and size of ICU, the number of patients undergoing RRT, reasons for initiating RRT, the RRT modes, the anticoagulation and the complications of RRT and so on. A total of 33 valid questionnaires were obtained, with a recovery rate of 100%. The result showed that there were 38 803 patients admitted to the selected ICUs during investigation, and 5 456 of them (14.06%) received RRT. In most ICUs, the reasons of initiating RRT were renal failure, sepsis and volume overload. The mode of RRT was mainly continuous venovenous hemofiltration (CVVH), which was followed by continuous venovenous hemodiafiltration (CVVHDF). Carbonate replacement fluid was the first choice. Heparin was the dominant anticoagulant, and there was an increasing trend in the use of citrate anticoagulation simultaneously. However, heparin-free anticoagulation used mostly in bleeding patients. Overall, the RRT modes and anticoagulation methods were single. Thrombosis was the main iatrogenic factor interrupting RRT in most ICUs, and also the reasons for complications related to catheter or circulation pipeline. It still showed an ineffective anticoagulation of RRT even after increasing the dosage of anticoagulants. RRT is an important organ support method in ICU, which has been widely carried out in ICUs of Tianjin and continues to expand. Despite the positive performance, it still needs to be improved and standarized in some aspects, such as the diversification of RRT modes, anticoagulation, and the complication prevention.

Stuck mechanical valve complication in non-COVID-19 patients during COVID-19 pandemic: single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Background Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. Purpose We wanted to explore how did the COVID-19 pandemic restrictions impacted mechanical valve replacement patients on chronic anticoagulation and the long-term consequences of limiting their access to health service. Methods We present a series of 10 patients on warfarin anticoagulation therapy who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Results Eight patients were female, two of whom were pregnant at the first trimester and eventually went on to receive an abortion; six patients received urgent valve replacement cardiac surgery; four patients were managed medically e.g. with heparin; none had thrombolytic therapy. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization including intensive care admission, with high in-hospital mortality rates and high costs were necessary. Mean hospital admission time was 27.5 ± 18.5 days. The cost of treatment, as average estimated reimbursement, was 11,000 USD for medical admission only, and 43,200 USD when surgery was required, up to 64,000 USD when ECMO was part of patient management. Conclusion Despite governments’ efforts to implement telemedicine and virtual clinics, COVID-19 restrictions and health-messaging affected the routine follow-up of non-COVID-19 patients. We report dramatic consequences to this drastic change in healthcare: clinical complications, lost lives and inflated healthcare costs in patients with a prosthetic valve. We believe that non-COVID-19 patients have paid, and will continue to pay in the future, a price that is much greater than those patients who have suffered from COVID-19. Active engagement of patients should be implemented in a time of emergencies, and further studies should address the efficacy and cost-effectiveness of public policies aimed to decrease the burden of avoidable complications and missed diagnoses. Abstract Figure. Fluoroscopy in a 70 years old patient

Loss of engagement in controlling chronic anticoagulation therapy during Covid-19 stringency measures. A single center experience of disproportioned increase of stuck mechanical valves.

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.

Abstract 8899: DOAC Use for Stroke Prevention in Patients with Atrial Fibrillation and Elevated Body Mass Index

Background: The incidence of comorbid obesity and atrial fibrillation (AF) has been increasing. Direct Oral Anticoagulants (DOACs) have become the first-line agents for cerebrovascular accident (CVA) prophylaxis in patients with AF due to their superior efficacy and lower bleeding risk when compared to coumadin. The incidence of acute ischemic CVA while on a DOAC in the non-obese population is 1.2%. Evidence on the efficacy of DOACs in preventing AF related CVAs in the obese population is limited. Methods: Electronic medical records from 8 hospitals within the same health system were queried. Patients age > 18 years with a BMI > 40 kg/mm 2 and AF on a DOAC (Rivaroxaban, Apixaban, or Dabigatran) were included in our study. Individual charts from 2010 to 2020 were reviewed for neuroimaging (computed tomography and MRI) following the start date of a DOAC confirming the presence or absence of an acute hemorrhagic or ischemic CVA. Results: We included 1935 patients in the study. Acute ischemic CVA was noted in 17 patients (0.9%) by head CT (11/17 confirmed by MRI). Hemorrhagic CVA was noted in one patient (0.1%) by head CT. 155 (8%) had a head CT without evidence of CVA, of which, 5 (3.2 %) had evidence of an acute ischemic CVA by MRI. Therefore, 22 patients (1.1%) had evidence of acute ischemic CVA on neuroimaging. The remainder of patients (N = 1762, 91.1%) did not have indications for neuroimaging and were considered to have successful CVA prophylaxis. In total, 1912 (98.8%) of patients with a BMI > 40 treated with a DOAC for AF did not demonstrate neuroimaging evidence of CVA. Conclusions: Although we expected to find higher CVA rates due to ineffective anticoagulation in the obese population, DOACs appear to be an effective therapy for CVA prophylaxis in obese patients with AF. The incidence of acute ischemic CVA in the obese population while on a DOAC is comparable to the non-obese population. Further prospective studies are needed to confirm the findings of this analysis.

Impact of anticoagulation status on recanalization and outcome of cerebral venous thrombosis

Effective anticoagulation status may determine the recanalization and outcome of cerebral venous thrombosis (CVT). We report impact of anticoagulation status on recanalization and outcome of CVT. This is a retrospective study on 126 patients with CVT diagnosed on magnetic resonance venography (MRV). Their clinical features and risk factors were noted. The data were retrieved from a prospectively maintained registry, and international normalized ratio (INR) was noted after discharge till 3 months. All the patients were on acenocoumarol. Based on INR value, patients were categorized as Group A (effective anticoagulation INR within the therapeutic range or above) and Group B (ineffective anticoagulation INR > 50% below the therapeutic range). A repeat MRV at 3 months was done for recanalization. Outcome at 3 months was evaluated using modified Rankin Scale (mRS), and categorized as good (mRS ≤ 2) and poor (mRS 2 or more) 101(80.2%) patients were in group A and 25(19.8%) in group B. Their demographic, risk factors, magnetic resonance imaging (MRI) and MRV findings were comparable. On repeat MRV, recanalization occurred in 22/24(91.7%); 15(88%) in group A and 7(100%) in group B. Recanalization was independent of coagulation status. Seven (5.6%) patients died and 107(84.9%) had good outcome; 85(84.2%) in group A and 22(88%) in group B. Kaplan Meier analysis also did not reveal survival or good outcome benefits between the groups. In CVT, outcome and recanalization at 3 months are not dependent on coagulation status. Further prospective studies are needed regarding duration of anticoagulant and its impact on recanalization and outcome.

Evaluation of Patients with Ineffective Anticoagulation after Left Ventricular Assist Device (LVAD) Implantation: Early and mid term follow up

Reports about discontinuation of anticoagulant therapy in LVAD patients are very limited. We reported that our experience of discontinuation of warfarin and aspirin therapy due to bleeding and ineffective international normalized ratio (INR) in patients with LVAD. From June 2013 to June 2019, hundred and forty seven patients that underwent LVAD implantation at our department. We analyzed outcomes of patients in whom warfarin and aspirin therapy had to be discontinued due to bleeding and temporary warfarin resistance during ongoing support with LVAD. None of these patients received any anticoagulation therapy until their bleeding event was over. INR <2 was defined as ineffective INR. We collected baseline and follow-up data, including patient characteristics, history of atrial fibrillation, history of heparin-induced thrombocytopenia, renal function at time of discontinuation. We checked speed, flow rates and power consumption parameters of pump, lactate dehydrogenase (LDH), creatinine, total bilirubin and INR level daily. After patients were discharged from the hospital, they returned to our center for follow-up, device review and clinical assessment. Of thirty five (23.8%) patients, mean age was 41 ± 16 (19-65) years, mean follow up time was 645.7 ± 430 (52-1315) days. Thirty patients had to discontinue warfarin due to bleeding and ineffective INR due to warfarin resistance in five patients. Mean duration of ineffective INR was 24.5 ± 12.1 (9-45) days. In one of the patient with intracranial hemorrhage, pump thrombosis was encountered, and his pump had to be exchanged with an urgent operation. There were not any other adverse events in this patient population. Mean follow-up time after ineffective INR situation was 344 ± 417 (94-1240) days. No delayed rehemorrhages or pump complications were observed after resuming aspirin and warfarin therapy. Despite advances in device technology and treatment strategies, prospective, controlled studies are needed to determine the new anticoagulation regimen that most effectively balances bleeding and thrombosis in LVAD patients.

Prosthetic valve thrombosis - association of genetic polymorphisms of VKORC1, CYP2C9 and CYP4F2 genes.

Prosthetic Valve Thrombosis (PVT), in spite of the advances in the valve design and the material used, remains a serious complication of mechanical cardiac valve replacement. The factors influencing the development of PVT are: thrombogenicity of the valve, hemodynamics of the transprosthetic blood flow and ineffective anticoagulation. Genetic polymorphism of the genes VKORC1 (-1639 G > A and 1173 C > T), CYP2C9 (∗2 & ∗3 alleles) and CYP4F2 (1347 G > A) are known to influence the anticoagulant dose-effect response. Since there has not been any earlier study on the direct influence of gene polymorphism on the development of PVT, we investigated into this association.Genotyping for the genes VKORC1, CYP2C9 and CYP4F2 was carried out by conventional PCR-RFLP method for 91 consecutive PVT patients. Subjects of our earlier study served as controls (n = 136).Female patients and patients with smaller prosthetic valve size were more prone to developing PVT (68%, n = 62). Patients bearing A allele of CYP4F2 1347 G > A polymorphism exhibited a fivefold increased risk of PVT (OR = 5.022 (1.39–18.04), P = .013). G allele of VKORC1 when analyzed in combination of genotypes showed a fourteen fold increased risk for developing PVT (OR = 14.25 (5.52–36.77), P = 0.001). CYP2C9 (∗2&∗3) gene polymorphism did not show any significant association with PVT (OR = 1.54 (0.128 – 18.82), P = .731).Patients bearing A allele of CYP4F2 showed an increased risk of developing PVT in our case – control study.

Investigation of Left Atrial Spontaneous Echo Contrast as a Marker Indicating Ineffective Anticoagulation in Patients with Mitral Valve Replacement Receiving Warfarin Spontaneous Echo Contrast Indicates Stroke

Investigation of Left Atrial Spontaneous Echo Contrast as a Marker Indicating Ineffective Anticoagulation in Patients with Mitral Valve Replacement Receiving Warfarin Spontaneous Echo Contrast Indicates Stroke

Interventional Left Atrial Appendage Closure in Atrial Fibrillation: 5-Year Experience from Wellington Hospital

Background: Left atrial appendage closure (LAAC) has a class IIb indication for stroke prevention in patients with atrial fibrillation (AF) and contraindications to anticoagulation. Method: Patients referred to Wellington Hospital for LAAC were enrolled in a registry since 2014. A moratorium was placed on LAAC in New Zealand in 2014; thus, patients who were shortlisted but did not get a LAAC were used for comparison. Procedural details and outcomes were retrospectively analysed. Primary end points were stroke and all-cause mortality. Secondary end points were myocardial infarction, cardiac failure, venous thromboembolism, and AF admissions. Results: A total of 27 patients were enrolled: 12 underwent LAAC and 15 were treated medically. Both groups had similar baseline demographics. Indications for closure were bleeding (n = 21), ineffective anticoagulation (n = 4), and drug intolerance (n = 2). The mean length of follow-up for LAAC and medical groups was 47.5 and 45 months/patient, respectively. At 1 year, primary end points occurred more frequently in the medically treated group (3 vs 0; hazard ratio [HR], 0.12; 95% CI, 0.02–0.87 [p = 0.034]). By 5 years there was no statistical difference in primary end points between the LAAC and medical group (4 vs 7; HR, 0.75; 95% CI 0.2–2.6 [p = 0.6]). Secondary end points were numerically less common in LAAC, as were strokes, including recurrent strokes (4 vs 12). The median event-free survival was 1563 and 607 days for the LAAC and medical groups, respectively. Conclusion: Our early experience with LAA closure appeared to favour LAAC. At 5 years there were fewer strokes and some favouring parameters in the LAAC group, but, overall, no statistical difference was seen between the two small cohorts.

How Long Can We Safely Follow Patients with Ineffective Anticoagulation after Left Ventricular Assist Device Implantation

How Long Can We Safely Follow Patients with Ineffective Anticoagulation after Left Ventricular Assist Device Implantation

Fibrilación auricular: enfoque para el médico no cardiólogo

Atrial fibrillation is the most frequent arrhythmia. Its classification according to pattern and clinical type allows to decide the therapeutic strategy to use, that most include control of symptoms and prevention of cardioembolic events. The election of the treatment depends on the presence of triggering events, risk factors for thromboembolism, risk factors for bleeding, cardiac function, patient funcionality, medication costoefectiveness and health care access. The type of anticoagulant has to be supported on the type of atrial fibrillation and the presence of contraindications, documented ineffective anticoagulation or high risk of failure to warfarin. In case of contraindications for anticoagulation this could still be used in high bleeding risk patients, when risk factors are controllable or corrected; leaving left atrial appendage closure as an option for patients that remain in high risk for bleeding events.

Assessment of the mean time in the therapeutic INR range and the SAME-TT2R2 score in patients with atrial fibrillation and cognitive impairment.

INTRODUCTION Most patients with atrial fibrillation (AF) are elderly and may have an increased risk of cognitive disorders. Low mean values of the therapeutic international normalized ratio (INR) range (TTR) (≤60%) are associated with increased risk of stroke, vascular events, and bleeding complications. OBJECTIVES The aim of the study was to evaluate the efficacy of long-term anticoagulant therapy in patients treated with vitamin K antagonists (VKAs), depending on their cognitive functions. In addition, we used the SAMe-TT2R2 risk score to predict the risk of ineffective anticoagulation. PATIENTS AND METHODS The analysis comprised 154 patients (68 men and 86 women; mean age, 76 ±10 years) with AF and indications for long-term therapy with VKA (CHA2DS2-VASc score ≥1, HAS-BLED score <3). Cognitive functions were evaluated using the Mini-Mental State Examination (MMSE) score. The efficacy of VKA therapy was determined by the TTR values from the preceding 6 months of treatment. We used the SAMe-TT2R2 score to identify patients who were likely to have poor INR control. RESULTS Depending on the number of MMSE points, patients treated with VKAs were divided into 2 groups: patients with normal cognitive functions (MMSE score ≥27; n = 62) and those with cognitive impairment (MMSE score <27; n = 42). Despite the fact that all patients had indications for anticoagulant therapy, 50 patients (32%) received no VKAs on admission. The mean TTR value exceeded 60% in 61% of patients with an MMSE score of 27 points or higher, whereas mean TTR value was 28% in patients with an MMSE score of less than 27 (P <0.0001). Patients with a SAMe-TT2R2 score of 0 to 1 had higher TTR values than those with a SAMe-TT2R2 score of 2 or higher (r = -0.24; P <0.05 ). The cognitive status was significantly more impaired in patients with persistent and permanent AF compared with patients with paroxysmal AF (MMSE score, 25.8 ±3.7 vs 28.6 ±2; P <0.0001). CONCLUSIONS Cognitive disorders in patients with AF significantly reduce the efficacy of VKA therapy. The decision to administer VKA treatment should be based not only on the CHA2DS2-VASc and HAS-BLED scores, but also on the SAMe-TT2R2 score and the evaluation of the patient's cognitive functions.

AB0 blood types: impact on development of prosthetic mechanical valve thrombosis.

Objective:The non-O alleles of the ABO genotype have been associated with an increased risk of thrombosis. We aimed to assess the association between blood group status and prosthetic valve thrombosis.Methods:The association between AB0 blood group status and prosthetic valve thrombosis was assessed in this retrospective study. Transesophageal echocardiography was performed in 149 patients with a diagnosis of prosthetic valve thrombosis and in 192 control subjects.Results:Non-0 blood group type (p<0.001), presence of NYHA class III-IV status (p<0.001), and central nervous system (p<0.001) and non-central nervous system (p<0.001) emboli were significantly more prevalent in prosthetic valve thrombosis patients than in the control subjects. The incidence of ineffective anticoagulation was higher in patients with prosthetic valve thrombosis than in controls (p<0.001), as was the presence of moderate to severe left atrial spontaneous echo contrast (p<0.001). The non-0 blood prosthetic valve thrombosis subgroup had a higher incidence of obstructive thrombi and central nervous system thrombotic events than having 0 blood prosthetic valve thrombosis subgroup. Non-0 blood group, ineffective anticoagulation, left atrial spontaneous echo contrast, and a poor NYHA functional capacity were identified to be the predictors of prosthetic valve thrombosis.Conclusion:Our data demonstrate that patients with non-0 compared with 0 blood groups have higher incidence of prosthetic valve thrombosis and central nervous system embolism and similar rates of non-central nervous system embolism at presentation compared with 0 blood group type. Thus, non-O blood group may be a risk factor that may be prone to the development of prosthetic valve thrombosis in patients with prosthetic heart valves.

Hemolysate-mediated platelet aggregation: an additional risk mechanism contributing to thrombosis of continuous flow ventricular assist devices.

Despite the clinical success and growth in the utilization of continuous flow ventricular assist devices (cfVADs) for the treatment of advanced heart failure, hemolysis and thrombosis remain major limitations. Inadequate and/or ineffective anticoagulation regimens, combined with high pump speed and non-physiological flow patterns, can result in hemolysis which often is accompanied by pump thrombosis. An unexpected increase in cfVADs thrombosis was reported by multiple major VAD implanting centers in 2014, highlighting the association of hemolysis and a rise in lactate dehydrogenase (LDH) presaging thrombotic events. It is well established that thrombotic complications arise from the abnormal shear stresses generated by cfVADs. What remains unknown is the link between cfVAD-associated hemolysis and pump thrombosis. Can hemolysis of red blood cells (RBCs) contribute to platelet aggregation, thereby, facilitating prothrombotic complications in cfVADs? Herein, we examine the effect of RBC-hemolysate and selected major constituents, i.e., lactate dehydrogenase (LDH) and plasma free hemoglobin (pHb) on platelet aggregation, utilizing electrical resistance aggregometry. Our hypothesis is that elements of RBCs, released as a result of shear-mediated hemolysis, will contribute to platelet aggregation. We show that RBC hemolysate and pHb, but not LDH, are direct contributors to platelet aggregation, posing an additional risk mechanism for cfVAD thrombosis.

Early thrombus formation in patient with HeartWare left ventricular assist device presenting with acute heart failure

Heart failure is one of the leading causes of mortality and morbidity in the world. Heart transplantation is still the gold standard therapy despite emerging treatment options. Due to the limited number of available donors, the use of ventricular assist devices has increased. However, increasing incidences of complications are observed with using these devices. In this article, surgical treatment of a huge mobile thrombus formation in an inflow cannula due to ineffective anticoagulation in a 59year-old man who received a HeartWare ventricular assist device because of ischemic cardiomyopathy is presented.

Role of anticardiolipin antibodies in the pathogenesis of prosthetic valve thrombosis

Prosthetic valve thrombosis (PVT) is serious complication of valvular replacement surgery, and increased levels of anticardiolipin antibodies (aCL) are associated with thrombosis. The aim of this study was to evaluate the role of aCL in the development of PVT. We studied the aCL IgM and IgG levels in 114 patients with PVT and 80 healthy patients with prosthetic valves without PVT or a history of thrombosis. All patients underwent detailed transthoracic, transesophageal echocardiographic and clinical examinations. Blood samples were obtained after transesophageal echocardiography. Tests were repeated 12 weeks apart in patients with aCL IgM or IgG positivity. The mean age, sex, presence of atrial fibrillation and cardiovascular risk factors, elapsed time after surgery, and prosthetic valve type and location were similar between patients with PVT and those without. Ineffective anticoagulation was significantly higher among patients with PVT (p < 0.001). The aCL IgM values were significantly higher and positive (> 40 MPL) in the PVT group compared with the control group (10.58 ± 15.90 MPL to 3.70 ± 2.30 MPL, p < 0.001; 7.0 to 0 %, p = 0.016, respectively). The aCL IgG values were significantly higher and positive (> 40 GPL) in the PVT group compared with the control group (12.04 ± 17.58 GPL to 3.83 ± 2.56 GPL, p < 0.001 and 7.9 to 0 %, p = 0.01, respectively). According to international consensus documents, 16 patients had antiphospholipid syndrome. Ineffective anticoagulation and aCL IgM and IgG positivity were independent predictors of PVT in logistic regression analysis (multivariate r(2)= 0.648; p < 0.001, OR= 21.405, 95 %CI= 8.201-55.872; p = 0.008, OR= 1.322, % 95CI= 1.076-1.626; p = 0.005, OR= 1.288, 95 %CI= 1.079-1.538). Since the presence of aCL IgM and IgG positivity may cause a tendency toward PVT, these values should be examined in all patients with PVT.

Are low-molecular-weight heparins appropriately dosed in patients with CKD stage 3 to 5?

The aims of this study were to determine the serum antifactor Xa levels in patients with impaired glomerular filtration receiving low-molecular-weight heparins (LMWHs), monitor efficacy and complications during treatment, and determine the approach to dose adjustments of LMWH by using antifactor Xa levels in different levels of kidney dysfunction in a real world clinical practice. Patients with chronic kidney disease who had subcutaneous enoxaparin administration during hospitalization were included in this study. We obtained data on patient demographics, glomerular filtration rate, bleeding complications, and antifactor Xa levels. Patients were divided into four groups based on glomerular filtration rate (>60 ml/min, 30-59 ml/min, 15-29 ml/min, <15 ml/min). Target levels for antifactor Xa were accepted as 0.1-0.4 IU/ml for prophylactic use and 0.4-1.1 IU/ml for therapeutic use. There were 61 patients and 18 controls (40 women, 39 men, mean age 68 ± 12 years) available for analysis. Interpretation of antifactor Xa with regard to target levels has shown that levels were in therapeutic range in 33 patients (41.8%), subtherapeutic range in 38 patients (48.1%), and supratherapeutic range in eight patients (10.1%). Less than half of the patients at each level of kidney dysfunction had antifactor Xa levels within the therapeutic range. Three patients suffered major bleeding, two with supratherapeutic, and one with therapeutic antifactor Xa level. There were no complications of ineffective anticoagulation in patients with subtherapeutic levels. Inappropriate dosing of LMWH suggested by subtherapeutic and supratherapeutic antifactor Xa levels were very high in patients with different levels of kidney dysfunction.

Antithrombin Replacement During Extracorporeal Membrane Oxygenation

Heparin remains the predominant anticoagulant during extracorporeal membrane oxygenation (ECMO). Heparin acts by potentiating the anticoagulant effect of antithrombin (ATIII). Acquired ATIII deficiency, common in pediatric patients requiring ECMO, may result in ineffective anticoagulation with heparin. ATIII replacement may result in increased bleeding. Our objective is to determine ATIII's effect on anticoagulation and blood loss during ECMO. A retrospective chart review was performed of all patients at Children's Hospital of Wisconsin who received ATIII while supported on ECMO in 2009. ATIII activity levels, heparin drip rate, and activated clotting times (ACT) were compared before, 4, 8, and 24 h after ATIII administration. Chest tube output and packed red blood cell (pRBC) transfusion volume were compared from 24 h before ATIII administration to 24 h after. Twenty-eight patients received ATIII as a bolus dose during the course of 31 separate times on ECMO support. The median age of these patients was 0.3 years (range 1 day-19.5 years). ATIII activity increased significantly at 8 and 24 h after administration. No significant difference was noted in heparin drip rate, ACT levels, chest tube output, or pRBC transfusion volume. ATIII administration resulted in higher ATIII activity levels for 24 h without a significant effect on heparin dose, ACT, or measures of bleeding.

Effect of total parenteral nutrition on the duration of haemofilter circuit

An effective haemofilter circuit is essential for performing continuous renal replacement therapy (CRRT) efficiently and without interruption. Premature clotting is a major problem in the daily practice of CRRT associated with blood loss [1], increased workload and cost implications. Early clotting is related to various factors ranging from bio-incompatibility of the CRRT circuit material, the modality used, ineffective anticoagulation, to site of catheter placement. Shortened haemofilter circuit survival time due to high lipid content in total parenteral nutrition (TPN) has also been described in a case report [2]. We wish to determine whether TPN infusion led to shortening of haemofilter circuit duration.

Critical issues in preventing post-thrombotic re-ulceration

Critical issues in preventing post-thrombotic re-ulceration